PERIODONTAL FLAP SURGERY
CONTENTS
INTRODUCTION & DEFINITION CLASSIFICATION INDICATIONS&CONTRAINDICATIONS DESIGN & INCISION DIFFERENT FLAPS SUTURING TECHNIQUES
INTRODUCTION
The surgical phase of periodontal therapy seeks to improve the prognosis & esthetics of teeth Primary objective of surgical therapy is elimination of pathologic pocket walls,creation of stable, easily maintainable State & if possible promotion of periodontal regeneration Other objective is correction of morphological defects favoring plaque accumulation & pocket recurrence
DEFINITION
According to Glickman periodontal flap is a section of gingiva and/or mucosa surgically elevated from the underlying tissues to provide visibility of & access to the bone & root surface.
CLASSIFICATION
ON BASIS OF REFLECTION OF PERIOSTEUM ON BASIS OF PLACEMENT OF FLAP ON BASIS OF FLAP DESIGN
ON BASIS OF REFLECTION OF PERIOSTEUM
A) Full thickness All soft tissue including periosteum reflected to expose underlying bone. Needed in osseous surgery. B) partial thickness / split thickness Only epithelium & layer of connective tissue is included. Used when flap is to be positioned apically & operator doesnt want to expose bone.
On basis of placement of flap
A)REPOSITIONED /POSITIONED/ DISPLACED Can be located apical ,coronal or lateral to its original position. B)UNREPOSITONED/UNDISPLACED Located in its original position it had before surgery.
On basis of flap design
A) CONVENTIONAL FLAP Incisions for facial & lingual/palatal flap reach the tip or vicinity of interdental papilla Examples- modified widman flap,undisplaced flap, apically displaced. Uses-1) in narrow interdental spaces 2) when flap is to be displaced
B) PAPILLA PRESERVATION FLAP Entire papila is incorparated in one of the flap ADVANTAGE: 1) Better post surgical aesthetics 2) In bone regeneration techniques,for more protection of interdental bone.
INDICATIONS
Accessibility for SRP Deep infrabony pockets All osseous defects Regenerative procedures Grade II and grade III furcation involvement Pockets extending beyond MG junction T\t of periodontal abscess
Contraindications
Non cooperative pt Gingival pockets Shallow periodontal pockets Presence of active lesions Teeth with hopeless prognosis Unfavorable systemic factors
INCISIONS
FOR CONVENTIONAL FLAP
A) Horizontal Incisions B)Vertical/oblique releasing incisions
Horizontal incision 1) Internal bevel Incision 2) Crevicular Incision 3) Interdental Incision
INTERNAL BEVEL INCISIONS
Starts at a distance from gingival margin & is aimed at bone crest. OBJECTIVES 1)removal of pocket lining 2)conservation of uninvolved outer surface of gingival margin. 3)produces sharp thin margin for adaptation to bone-tooth junction.
CREVICULAR INCISIONS
Also termed as second incision Made from base of pocket to crest of bone This incision together with initial reverse bevel incision forms a V shaped wedge ending at or near crest of bone.
INTERDENTAL INCISION
Known as Third Incisions Used for removal of collar of gingiva around tooth. If no vertical incision is made the flap is called an ENVELOPE FLAP
VERTICAL/OBLIQUE RELEASING INCISIONS
Necessary when the flap is to be displaced apically. Extension must be made beyond mucogingival junction to the alveolar mucosa. avoid incisions in lingual/palatal region incision should not be placed in center of interdental papilla or radicular surface of tooth
VERTICAL/OBLIQUE RELEASING INCISIONS
Modified Widman Flap
Also k/as Unrepositioned Mucoperiosteal Flap (1965,Morris) PURPOSE 1)For expose root surfaces for instrumentation 2)For removal of pocket lining
STEPS
1)Internal bevel incision to alveolar crest starting 0.5to1mm of gingival margin 2)Reflection of gingiva 3)Crevicular incision from bottom of pocket to bone 4)Interdental incision
4)interdental incision
5)removal of granulation tissue 6)scaling & root planning 7)placement of interrupted
UNDISPLACED FLAP
Differs from modified Widman flap in that the pocket wall is removed with the initial incision Considered as internal bevel gingivectomy PURPOSE 1)surgically removes pocket wall 2)accesibility for instrumentation
UNDISPLACED FLAP
STEPS 1) Pockets measured & pocket bottom marked 2) Internal bevel incision carried to a point apical to alveolar crest 3) Crevicular incision 4) Flap reflected
5)Interdental incision 6)Removal of granulation tissue 7)Scaling & root planning 8) Suturing
UNDISPLACED FLAP
APICALLY DISPLACED FLAP
Used for pocket eradication &/or preserving or widening the zone of attached gingiva STEPS 1) Internal bevel incision 1 mm from the crest of gingiva & directed toward the crest of bone 2) Crevicular incision 3) Vertical incisions extending beyond mucogingival junction 4) Interdental incisions 5) Removal of granulation tissue 6) Scaling & root planning 7) Contineous, individually anchored suture
PALATAL FLAPS
The palatal tissue is all attached keratanized tissue and has none of the elastic properties associated with other gingival tissue. Therefore the palatal tissue can not be apically displaced nor can a partial thickness flap be accomplished. Initial incision should be such that when the flap is sutured it should adapted at root bone junction. For thick tissues horizontal gingivectomy incision followed by internal bevel incision starting at the edge of this incision and ending of lateral surface of underling bone.
If flap is thick it is best to thin the flap before their complete reflection. If intention of surgery is debridement the internal bevel incision is so planned that the flap adapts at root bone junction when sutured. If osseous resection is to be done the incision should be planned to compensate for the lowered level of bone when flap is closed.
Distal molar surgery
For Maxillary molars For mandibular molars
Suturing
Wound closure Maintain hemostasis Permit primary healing Support marginal tissue Reduce postop pain Prevent bone exposure
Nonabsorbable
Silk-braided Nylon-monofilament (ethilon) EPTFe (Gore-tex) Polyester braided (Ethibond)
Absorbable
Surgical: gut Plain gut ; monofilament (30 days) Chromic gut; monofilament(45-60days)
Synthetic
Polygycolic: braided (16-20days) (Vycryl; ethicon) (dexon davis &geck) Polyglecaprone: monofilament (90-120days) (monocryl; ethicon) Polygyconate monofilament (maxon)
Technique
Ligation interdental ligation direct loop figure of eight sling ligation
Types
Horizontal matress sutures Conteneous independent sling suture Anchor suture open anchor close anchor Periosteal sutures
